Billing the Correct Evaluation and Management CPT® Code? (Part 2)
In my last article on Evaluation and Management (E/M) coding, I discussed how to determine the level of examination performed when determining which E/M code level to bill. In this article, I will discuss how to determine the level of the third key component of E/M coding, Medical Decision Making. According to the Current Procedural Terminology (CPT®) Code book and CMS, medical decision making is establishing a diagnosis for a patient’s condition and/or selecting a management option to treat the patient’s current condition. (1, 2)
There are four levels of medical decision making: Straightforward, Low Complexity, Moderate Complexity, and High Complexity. In order to determine the level of medical decision making one has met a physician must first look at the three elements used to determine each level. The first element is the number of possible diagnoses and/or the number of management options that must be considered in treating the patient. The second element is the amount and/or other information that must be obtained, reviewed, and analyzed in order to treat the patient. The last element that determines the level of medical decision making is the risk of significant complications, morbidity and/or mortality as well as co-morbidities associated with the patient’s presenting problem. (1, 2)
Let’s look at the first element that determines the level of medical decision making, the number of diagnosis and management options. This is based on the number of problems with which a patient presents and the type of problems addressed during the E/M service. Is the problem undiagnosed or a previously diagnosed problem? Is the problem improving, getting worse or failing to change? How many diagnostic tests are needed to determine a diagnosis? Was the advice of another health professional needed to help determine a diagnosis? Answering these questions can help a practitioner determine if the number of diagnosis or management options are “minimal”, “limited”, “multiple”, or “extensive”.
Straightforward decision making requires a minimal number of diagnosis or management options where high complexity medical decision making requires an extensive number of diagnosis or management options. When documenting the number of patient diagnosis and/or management options it is very important to include an assessment, a clinical impression or diagnosis regarding patient management and future patient evaluations. For example, if the patient’s diagnosis is already established the documentation should state if the patient’s condition has improved, is controlled, resolving or resolved. If the presenting problem does not have an established diagnosis then the assessment may be in the form of differential diagnosis or as a diagnosis that is “possible”, “probable” or to “rule out”. An example would be a probable diagnosis of a herniated disc before the patient has had a CT or MRI to confirm the diagnosis.
It is also important to document any new treatments, or any changes in existing treatments including any patient instructions, therapies, exercises, etc. In addition, if the case requires any referrals or consultations, this should be documented as well. Documenting this information supports the level of diagnosis or management element (minimal, limited, multiple or extensive) to determine the type of medical decision making. (1, 2)
The second element used to determine the level of medical decision making is the amount and/or complexity of the data to be reviewed. There are four levels: none or minimal, limited, moderate, extensive. This element of medical decision making is determined by the decision to request test results and past medical records, the amount of data to be reviewed by the practitioner and/or the decision to obtain a history from a source other than the patient. Documentation to support the level of complexity or amount of data reviewed should include any diagnostic test ordered, planned, scheduled, or performed at the time of the E/M service.
A copy of any diagnostic test results that the practitioner may review should be included in the patient’s file and these results should be signed and dated by the reviewing doctor or a note describing the test results can be documented in the patient’s file. If a practitioner obtains old records or gets an additional history from someone other than the patient, this must also be included in the patient’s file. In addition, any discussions about the diagnostic test with the physician who performed or interpreted the test should be documented.
The third element used to determine the complexity of medical decision making is the Risk of Complications and/or Morbidity or Mortality which is minimal, low, moderate or high. The risk of significant complications, morbidity and/or mortality is based on the risk associated with the following: the risk related to the presenting problem(s), the risk of any diagnostic procedures and the risk of management options during and following any procedure or treatment. (2)
The highest level of any one category determines the overall risk of complications, morbidity or mortality. The determination of “risk” is complicated and not easily measured. The Evaluation and Management Service Guide by CMS has a table of risk that can assist in determining whether the risk of significant complications, morbidity and/or mortality is minimal, low, moderate or high. (2) Most presenting problems, which we see as chiropractors, fall in the low level of risk. Moderate and high-risk levels have more life-threatening illnesses and require invasive diagnostic procedures and management options. When documenting the level of risk, it is important to include any comorbidities and/or underlying diseases or factors that can raise the complexity of medical decision making. Any surgical or invasive diagnostic procedures that are ordered, planned, scheduled or performed at the time of the E/M encounter should be documented.
The following chart shows the element levels for each of the four types of medical decision making. Two of the three elements must be met or exceeded to qualify for one of the types of decision making.
Documentation is very important in order to support one’s level of medical decision making. There are no specific measurements to determine which level a practitioner has completed. As a result, this leaves more room for interpretation by a third party reviewer if one is ever audited.
In my next article on E/M coding, I am going to discuss the three contributory factors (counseling, coordination of care and the nature of the presenting problem) and when Time plays a role in choosing the level of E/M service. I will also summarize the information from the first three articles, documentation and E/M “red flags”.
- Current Procedural Terminology (CPT®) Professional Edition, American Medical Association, 2010, p.10.
- Evaluation & Management Services Guide, CMS, July 2008, p.20 -24.